Hartshill Medical Centre

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment, we rated this key question as good. At this assessment, the rating has changed to requires improvement.

The service was in breach of legal regulation in relation to good governance.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff were aware of the practice vision and strategy, which was displayed in areas throughout the practice and staff told us this was openly discussed. The practice development plan was evolving with further development expected.

The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff told us leaders in the practice were accessible and responded to any concerns raised. Staff felt the culture within the practice was supportive and the leadership team were very good at listening and staff felt comfortable approaching any of the team. Staff fed back they felt all the leaders had different skills and experience which they were able to learn from. This was in line with the practices mission statement. We saw the leadership team worked with other practices in the primary care network.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The practice had established Freedom to Speak up arrangements with other practices in the primary care network. Staff were aware of how to raise concerns.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Policies and procedures to promote diversity and equality were in place. Staff we spoke with told us they felt the practice had a good mix of people and skill set, with every member of staff adding something to the practice. Adjustments had been made to ensure all staff were valued, for example flexible working arrangements were in place. The leadership team told us they welcomed training requests from staff members, as they felt this added to better patient care. Staff we spoke with told us the leadership team encouraged staff to request training and stated the leadership team were always interested in their feedback from the training attended.

The service did not have clear systems of accountability and good governance.

Although the provider had governance systems in place they were not always effective. Staff recruitment had been identified by the provider as an area for improvement on their practice development plan, we found gaps in recruitment process, in relation to health checks, immunisation history and employment history.

Governance systems had not identified that prescription stationery was not secured in a way that could be audited, so that every prescription could be accounted for, in line with guidance.

Processes had not identified the lack of oversight over the complaints and including making people aware of next steps and time scales.

The practices electronic software system to support patient safety alerts, for example MHRA, were not always addressed effectively.

The recall system in place to support people with long term conditions did not always work effectively, meaning that some people were not followed up as recommended by NICE guidance.

Leaders and managers supported staff, and there was a clear guidance on individual roles and responsibilities. Managers met with staff to complete appraisals.

There had been some change within the leadership team, which had meant leaders had had to take on additional roles and learning.

Staff could access all required policies and procedures.

Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Managers recorded any actions arising from these meetings and ensured they shared these with staff.

Staff took patient confidentiality and information security seriously.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The provider worked with other practices within their primary care network to offer extended access, and flu and covid vaccination programmes. Staff worked with community healthcare services, including a service that is centred on the care of those at higher risk of hospital admission and dentistry. The practice also attended regular meetings with the local integrated care board.

On a monthly basis the patient participation group attended the practice to seek the views of people using the service.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

The practice worked in conjunction with a local university to offer placement opportunities for medical students. There were policies in place to support this.

The practice had a quality improvement plan in place to help drive improvements in services. All staff were encouraged to put forward and test out new ways of working.

The practice was veterans friendly accredited, and they had undertaken a quality improvement project on this which increased the number of registered veterans the practice provided support to. This project was ongoing; we saw that it had been reviewed recently and the date for the next review.